The edition · Pulmonology
The comfort feature on a CPAP machine is making the treatment worse
Expiratory pressure alleviation halved peak inspiratory flow and raised residual apnoea without improving adherence; mucus plugging on CT marks exacerbation risk where emphysema is mild; and interval training in fibrotic lung disease found no advantage over continuous training.
The edition in brief
Five findings for the pulmonology desk. In 29 adults with severe obstructive sleep apnoea, activating expiratory pressure alleviation on nasal CPAP halved peak inspiratory flow during flow limitation (0.19 versus 0.38 L/s), raised the manually titrated therapeutic pressure from 9.17 to 11.40 cmH2O, and left residual apnoea-hypopnoea index higher on both fixed (3.7 versus 1.3 events per hour) and automatic CPAP, with no difference in adherence at about seven hours either way. A prospective cohort of 215 patients with COPD stratified by quantitative CT mucus plug score and emphysema found all three subgroups carried roughly threefold higher adjusted odds of acute exacerbation than the low-mucus, low-emphysema reference, with mucus plugs significant only where emphysema was low. A single-centre randomised trial in 150 patients aged 80 or older on prolonged mechanical ventilation found multicomponent pulmonary rehabilitation achieved successful weaning in 45.3% against 12.0% with standard rehabilitation (adjusted hazard ratio 5.11, 95% CI 2.46–11.23), with less ventilator-associated pneumonia at 60 and 90 days and no mortality difference. In 131 people with fibrotic interstitial lung disease, high-intensity interval training produced the same improvement in cycle endurance as moderate continuous training (mean difference −63 seconds, 95% CI −195 to 68), with no adverse events in either arm. And a network meta-analysis of nine trials found dacomitinib and osimertinib improved overall survival against first-generation EGFR inhibitors, with no agent clearly superior across all outcomes.
Expiratory pressure relief undoes some of what CPAP is for
Turn expiratory pressure relief off during titration and in anyone with high residual events — it raises the pressure needed and worsens control without improving adherence.
Mucus plugging marks exacerbation risk where emphysema is mild
In a patient with COPD and limited emphysema who keeps exacerbating, look for mucus plugging on CT — it marks risk the emphysema score misses.
Interval training in fibrotic ILD is an alternative, not an upgrade
Prescribe whichever of interval or continuous training the patient will actually attend — in fibrotic interstitial lung disease they produce the same result.
EGFR inhibitors: two improve survival, none wins outright
Where a third-generation inhibitor is affordable, osimertinib has the most consistent evidence; where it is not, the overall survival cost of a first-generation agent is roughly a hazard ratio of 0.8.
The inhaler that does not work is usually the one being used wrongly
Watch the patient use their inhaler before escalating therapy — technique failure is commoner than treatment failure.
Structured rehabilitation nearly quadrupled weaning success in ventilated over-80s
Refer ventilated patients over 80 for structured multicomponent rehabilitation rather than standard care — weaning success was nearly four times higher.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for pulmonology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free